HomeMy WebLinkAboutSeptic Pumping Slip - 154 REA STREET 11/17/2017 ����������
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C.fv/T[]Vyn of North Andover
System Pumping Record TOWN OFNDRTHANDOVER
Form 4 HEA[[11DERARTMEN5
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be Submitted to
the local Board of Health orother approving authority within 14days from the pumping date in
accordance with 310C[VIR16.351.
A. Facility Information
Important:When
Ming out forms 1. System Location:
on the computer,
use only the tab 154Rea Street
key mmove your *dmmyu
cursor-««not North Andover MA 01845
use the return
key. City/Town State —'Code
--
2. System Owner:
~---�
Christine Chiles
Address(if different from location)
ityfTown State Zip Code
978-380-3728
Telephone Number
B. Pumping Record
10/24/2017 1500
1. Date of Pumping 2. Quantity Pumped.
Gallons
3, Type ofsystem: El Cesspool(s) Septic Tank F1 Tight Tank El Grease Trap
[] Other(describe):
4. Effluent Tee Filter present? Yeo No |fyes, was itcleaned? Yes No
5. Condition ufSystem:
Good, system operatingproperly
6. System Pumped By:
Jason Elliott S71437
Name Vehicle License Number
Ivester and Elliott Services LLC-DBA Jason
Elliott Pumpin
7. Location where contents were disposed:
GLSD